Regarding Health care insurance 'speak'

[Sheepshank]

Last edited Wed Oct 2, 2013, 04:29 PM - Edit history (1)

I understand what co pays are.

Can someone in the know, please explain to be the difference between "Out of Pocket Max" and "Deductable"?

[enlightenment]

1. Here:

You pay copays when you see the doctor.
Coinsurance is how you and your insurance company split up your care.
Maximum out-of-pocket is the largest amount you will pay for treatment in one year.
Deductibles are the portion you must pay before your insurance pays its share.

[upaloopa]

2. I have a high deductible plan.

I don't use health care much. I also have a health savings account that goes with it. My employer puts in so much to the HSA each pay day. My co pays and medications go toward the deductible. But after that I get 80/20 coverage meaning I still have to pay 20% of costs up to $3000 then I don't have to pay any more. The $3,000 is my out of pocket limit. So far I have never met my deductible in any year. My HSA pays for my meds.
So the most I would have to pay in any year is $4,500
plus my share of the premiums.

[cbdo2007]

3. $3,000 deductible, $5,000 oop max example

you pay out of pocket til you hit $3,000 deductible, then you start paying coinsurance for each visit (like 10% or 20% or something).

Once you reach $5,000 worth of all paid services for the year, you don't have to pay coinsurance or copay or anything, it's all covered.

Most people probably pay less than half of their deductible throughout the year, but if something catastrophic happens it's nice to know your portion would be capped at $5,000.

[Sheepshank]

4. Generally does the money paid as a deductable go towards the out of pocket max?

It does for me at the moment, and I'm getting people trying to state that ACA is going to gouge people by requiring both to be paid separately

[SharonAnn]

5. Yes, because it is "out of pocket". As long you are using doctors, etc. approved by your insurance

[cbdo2007]

6. If you have an Out of Network benefit, that amount would count toward the OOP max as well.

An HMO doesn't have an out of network benefit usually, so in that case you would have to go in network for any of it to apply to your max amounts.

PPO usually DO have an out of network benefit and therefore should count toward the OOP max.

[cbdo2007]

7. More lies about the ACA!! Ugh, that makes me so mad that people spread so much

misinformation trying to confuse people, rather than be helpful.